The Neuroscience on the Web Series:
CMSD 642 Neuropathologies of Swallowing and Speech

CSU, Chico, Patrick McCaffrey, Ph.D

Chapter 9. Diagnosis of Apraxia

Primary diagnostic methods are listening to the patient's speech and observing oral motor movements. Present a series of speech and oral motor tasks to the patient. Apraxia is caused by lesions in Broca's area. Of course, damage to Broca's area can also cause Broca's aphasia. As Broca's aphasia is a non-fluent form of the disorder in which speech is labored, choppy and poorly articulated, it may be hard to differentiate between this syndrome and apraxia. One instrument that can help a clinician to make this distinction is the Token Test (DeRenzi & Vignolo, 1966). This test has five parts involving the manipulation of objects of different colors, shapes and sizes. It tests receptive grammar by requiring the patient to follow instructions like "put the red square on the yellow circle." Since patients with Broca's aphasia have difficulty comprehending grammatical morphemes like the preposition "on" they will do poorly on the test. Apraxics without aphasia, on the other hand, will have no difficulty following the commands unless they have limb apraxia and therefore cannot volitionally follow commands. Another test I have given routinely is the Boston Examination for Aphasia. It's a good test that just got better (2001). I was a reviewer for Williams and Wilkins Publishing Company to look closely at new edition and was favorably impressed.

It should be noted that a patient may well have both apraxia and Broca's aphasia.

Both limb and oral apraxia may be mistakenly diagnosed as an auditory comprehension deficit.

Non-Speech Tasks

Begin with vowel production. Go all the way around the vowel triangle (quadralateral). Now have the patient perform diadochokinetic tasks: repeat /p/, /t/, /k/ then /ptk/ several times (rapid alternating task).

Speech tasks

  • produce words of progressively increasing length (e.g. hope, hopeful, hopefully; thick, thicker, thickening;); apraxic patients performance tends to deteriorate as words increase in length;
  • repeat several multisyllabic words three times (e.g. butterfly, butterfly, butterfly); production may improve with some apraxic patients;
  • repetition of sentences
  • conversation
  • picture description
  • oral reading
  • counting to 20
  • days of the week
  • months of the year

Motor Speech Evaluation 
(suggested by Wertz et al., 1984, p. 98):

This is a screening tool which should take less than 20 minutes to administer. Three steps may be required to obtain useful data. If the patient does not respond in such a way as to give diagnostic information, repeat the stimuli. If the second response is still ambiguous, cue (e.g. "Listen, watch me, and do what I do").

Scoring the Motor Speech Evaluation can be descriptive:

Use "A" for apraxic productions, "P" for paraphasias, "D" for dysarthria, "U" for nondiagnostic errors, "O" for other errors, and "N" for normal responses. It can also utilize the PICA 16- point scale, or narrow or broad phonetic transcription.

The tasks are conversation, vowel prolongation, repetition of monosyllable /p /, /t /, /k /; repetition of those in sequence, repetition of multisyllabic words; multiple trials with the same word; repetition of words that increase in length; repetition of monosyllabic words that contain the same initial and final sound; repetition of sentences; counting forward and backward; picture description; repetition of sentences used volitionally to determine consistency of production; and oral reading.

Generally, apraxic patients will reveal their deficits in conversation by producing apraxic articulatory errors and abnormal prosody. Usually they have no problem with vowel prolongation or repeating single monosyllables. With the sequence of /ptk/, there may be initiation difficulty, substitution, omission, or rearrangement of the syllables; slow rate; equal and even stress; stops, starts, and reattempts to produce the sequence. Similar errors should be evident with multisyllabic words and short phrases. Repeated trials on the same word may show inconsistent errors. Words of increasing length should show more errors on the longer words. Monosyllabic words beginning and ending with the same sound may show more errors in initial position, but not necessarily. Sentences and picture description will produce apraxic errors in articulation and prosody. Counting forward and backward contrasts automatic speech versus volitional speech, with more errors expected on the latter. Having the patient repeat sentences he/she produced earlier allows the examiner to check for consistency, with the apraxic expected to be inconsistent. Oral reading of the "Grandfather Passage," which contains most of the sounds of English, allows comparison with repetition tasks and more volitional tasks.

Some oral movement tasks (suggested by Darley, 1978 and DeRenzi et al, 1966; cited in Meitus & Weinberg, p. 269): (use verbal instruction alone at first; if patient cannot perform, then demonstrate and observe his/her imitation)

  • stick out your tongue
  • puff or blow
  • pucker up your lips
  • try to touch your nose with the tip of your tongue
  • bite your lower lip
  • whistle
  • move your tongue in and out of your mouth
  • lick your lips
  • clear your throat
  • click your teeth together once
  • smile
  • click your tongue as if imitating the sound of a galloping horse
  • chatter your teeth as if you are cold
  • try to touch your chin with the tip of your tongue
  • cough
  • puff out your cheeks
  • wiggle your tongue from side to side
  • show how you would kiss someone
  • alternately pucker and smile
  • yawn

The clinician should make qualitative judgments of the patient's performance, eg., consider the presence of:

  • accurate movement patterns preceded by trial and error
  • searching movements of the tongue or lips
  • accurate movement preceded by pauses
  • crude, awkward, erratic, or extraneous oro-facial movements
  • overall gesture patterns which are grossly acceptable, but defective in terms of amplitude, accuracy, or speed
  • perseverated movement

Commercial Instruments Available

Apraxia Battery for Adults (ABA) by Barbara Dabul (1979)

Dworkin-Culatta Oral Mechanism Examination, (1980)

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Other courses in the Neuroscience on the Web series:
CMSD 620 Neuroanatomy | CMSD 636 Neuropathologies of Language and Cognition

Copyright, 1998-2011. Patrick McCaffrey, Ph. D. This page is freely distributable.